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Revenues and Benefits ServiceWakefield One, Wakefield Council, PO Box 700, Burton Street, Wakefield, WF1 2EB .uk01977 727000 Financial Assessment Form - Income and ExpenditureName:Claim Number:Address:Invoice Number:Income (after Tax and National Insurance) - please complete all the appropriate sections Your…Weekly Wage?Employers Name or Monthly Salary ?and AddressTax Credits ?IS/JSA/UC/ESA paid by DWP ?or other Benefit PIP, DLA etc. ?Please specifyhow oftenWeekly Child Benefit ?Partners…Wage?Partners Employeror Salary?plus any other amount your partner receives?Please specifyhow oftenOther Income… Please specify: eg Maintenance, Savings, Pension, Board etc. 1?Number of Children (under 18)Ages 2?3?Number of Adults (including you and your partner) Total income:Expenditure (per week, month, quarter, year?)Rent ?perarrears?perElectricity ?perarrears?perGas?perarrears?perWater?perarrears?perCouncil Tax?perarrears?perTelephone/Internet?perarrears?perMobile Telephone?perHire Purchase?perSatellite ?perTravel Costs - Car?perTV Licence?perTravel Costs - Bus/Train?perCredit Cards ?perFood/Toiletries?perCatalogue ?perClothing?perContents Insurance?Leisure?perOther please specify:1?per2?per3?perPlease note:We may request proof of any information providedSignature Date Telephone No ................
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